by Richard Mounce, DDS
The principles that govern the creation of excellent results in endodontics are universal and supercede brand or specific product recommendations.
While advocates may argue the best means in order to obtain treatment goals, fundamentally everyone should agree about the desired final result and what - in a clinical endodontic context - is required to achieve this end. To use a sailboat racing analogy, the destination is the same but irrespective of the boat or materials from which the sails are made. The goal is to get to the finish line as safely and efficiently (three-dimensional cleaning, shaping, and obturation of the canal space) as possible without mishap (without iatrogenic events).
Principles can be applied to many brands of endodontic materials to bring successful results. The converse, however, is not true. Great materials used without guiding principles cannot predictably take the clinician to the desired outcome.
Endodontics can be divided into three segments - the preoperative, intraoperative and postoperative components. Within these segments, principles exist that facilitate the best possible outcomes.
Preoperative considerations would encompass - among many other items - evaluation of the patient and tooth carefully for everything from restorability to addressing potential risk factors (for example, challenging access that might lead to perforation).
Intraoperative considerations would include providing excellent straight-line access, hand file exploration and negotiation of canals before rotary nickel titanium file use, copious irrigation with a bactericidal solution, recapitulation, creation of an adequate apical diameter, tug back in cone fit, and use of a warm obturation technique that three-dimensionally fills all the ramifications of the cleared pulp space.
Postoperative considerations include such issues as the placement of an excellent coronal seal, and recall visits that should be performed to monitor healing. Looking at endodontic treatment in this manner has value. Obtaining an excellent result in one part of treatment provides a platform for the rest of the procedure to proceed well so that the desired endpoint is achieved.
How does this translate into practical tools and principles that the general practitioner can take into the operatory?
For practical application, viewing endodontic treatment in a purely mechanical context is unproductive. Making an accurate diagnosis, obtaining patient consent after fully informing the patient, having needed equipment ready and set out for a procedure, and addressing restorability before making access (among other necessary preoperative tasks) sets the stage for a predictable and excellent result. Like a journey that must have a destination and preparation to ensure success, skipping steps is always unproductive.
Efficiency, profitability, and - most importantly - a satisfied patient are the results of a well-planned procedure. Just as wars well fought should be won before the first shot is fired, most great endodontic results are created long before access is made; they are a by-product of the clinician’s preparation.
A clinician who can avoid iatrogenic events by anticipating those events before they occur has significant value for all parties. This takes practice and dedication. It is valuable to carefully examine preoperative radiographs to determine where - for example - files may fracture, or ledges, blockages, and transportations of all types might result.
Finally, a clinician who understands his or her equipment and materials is a key component to the effective utilization of those items. While others may have their favored methods, I use K3 RNT files, SystemB technique, the Elements Obturation unit and RealSeal bonded obturation (all from SybronEndo, Orange, Calif.).
Clinicians who wish to try these materials or any new materials should first read about them extensively. They can do so on Web sites such as PubMed (www.pubmed.org) or Roots (RxRoots.com). They also can talk to opinion leaders in the community.
In addition, practicing on extracted teeth by shaving back the roots to expose the canals can be a valuable learning tool. I think it is better to learn to negotiate canals and how much pressure it takes to advance an RNT file safely in an extracted tooth than on a live patient.Hopefully, the treatment principles addressed in this column can be agreed upon by clinicians. I welcome your comments and feedback.
Dr. Richard Mounce lectures globally and is widely published. He is in private practice in endodontics in Portland, Ore. Among other appointments, he is the endodontic consultant for the Belau National Hospital Dental Clinic in the Republic of Palau, Korror, Palau (Micronesia). He can be reached at [email protected].